Robert J. Welsh, MD Vice Chief of Surgical Services for Patient Safety, Quality, and Outcomes Chief of Thoracic Surgery William Beaumont Hospital Royal Oak, Michigan, USA 1
ARE OUR OPERATING ROOMS SAFE? Not as safe as they could be. 2
Evidence for danger in the O.R. 3
Evidence for danger in the O.R. Orthopedic Surgeons 25% chance of performing wrong side surgery during their career. 4
Evidence for danger in the O.R. Hand surgeons -20% revealed that they had operated on the wrong side at least once. 16% had prepared to operate on the wrong side but were caught at the last minute by a colleague. Wachter, Robert M.D., Kaveh A. Shejania, M.D. Internal Bleeding, page 131. Meinberg, E.G., Stern, P.J., Incidence of wrong-site surgery among hand surgeons, Journal of Bones and Joint Surgery 85-A (2003). Pp 193-97 5
Evidence for danger in the O.R. Surgeons with the highest workloads reported the highest incident of operating on the wrong side. Wachter, Robert M.D., Kaveh A. Shejania, M.D. Internal Bleeding, page 131. Meinberg, E.G., Stern, P.J., Incidence of wrong-site surgery among hand surgeons, Journal of Bones and Joint Surgery 85-A (2003). Pp 193-97 6
Wall Street Journal Wed., Nov. 16, 2005 146 incidents [were reported] thirtythree percent of incidents resulted in permanent disability and 13% in patient death. Seventy-seven percent involved injuries related to an operation or other invasive intervention (visceral injuries, bleeding, and would infection/dehiscence were the most common subtypes) 7
Major complications occur in 3-20% of cases Gawande, AA, et al. Surgery 1999; 126:66-75 8
Potential Patient Harm Occurs everyday in operating rooms Incorrect timing of antibiotics No DVT prophylaxis Case delays Communication failures Incorrect sponge counts Mislabeled specimens 9
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Safety in Surgery www.jointcommission.org 11
Safety in Surgery In 75% of wrong side surgeries, or sentinel events, someone knew something and did not speak up. 12
Errors can occur because of the intense atmosphere of the OR, where surgeons are the captains of the ship, treated with deference because of their unique skills. As a result, nurses, prep technicians and other aides can be afraid to speak up if they spot a problem. Now, some hospitals are taking new steps to combat this fearful atmosphere. They are putting programs in place to improve surgeons attitudes about teamwork Surgery, Vol.133, No. 6 p.614-21, June 2003. 13
Safety in Surgery A survey of surgical team members attitudes about communication 40% of surgeons believe that junior team members should not question decisions of senior team members 40% of surgical nurses rated the quality of teamwork and collaboration with surgeons as low Sexton JB, et al. BMJ. 2000; 320:745-9 15
Teamwork Disconnect RN: Good teamwork means I am asked for my input Physician: Good teamwork means the nurse does what I say 16
System Failures Leading to Communication Breakdown Differences between team members goals Differences between team members interpretation or events Knowledge that did not make it into the team consciousness Due to fear of speaking up or assumption that others already know Environmental features Noise, lighting, new equipment or technology Dekker S. The field guide to human error investigations, 2002. 17
Our Clinical Work Environment No ability to control or predict workload Incomplete, conflicting information Rapidly changing, evolving scenarios Fatigue, sustained operations Performance pressure, life/death outcome Operational pressure Distractions & auditory overload 18
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Improving Communication Standardized work processes, creating independent checks, and learning from adverse events and strategies to reduce errors in teamwork. Pronovost, P.J. Health Serv. Res 41:1599-1617, Aug. 2006 Pronovost, P.J. Berenholtz, S.M. BMJ 337:963-965. Oct. 2008 20
Improving Communication Briefings and Debriefings are strategies to improve communication in the O.R. Makary, M.A. Jt. Comm. J Qual Patient Saf 32:351-355, Jun. 2006 Makary, M.A. Jt. Comm. J Qual Patient Saf 32:407-410, Jul. 2006 21
Improving Communication Surgical checklists have been shown to decrease death and complication rates Haynes, A.B. et al. NEJM 2009 Jan. 29; 360(5):491-499 22
Improving Communication Implementations of a medical team training program can reduce surgical mortality Neily, J. et al. JAMA 2010 Oct. 20; 304 (15):1693-1700 23
Improving Communication Utilizing briefings and debriefings are associated with reductions in or delays Nundy, S. Arch Surg. 2008;143(11): 1068-1072 24
Improving Communication Teamwork and communication in O.R. s can be improved by using briefings and debriefings Berenholtz, S.M. et al. 2009;35(8):391-397 Jt. Comm. J Quality Patient Saf. Makary, M.A. et al. J Am Coll Surg. 2007; 204(2):236-243 25
BEAUMONT HOSPITAL ROYAL OAK 26
Initial Steps Program developed in conjunction with Johns Hopkins Quality and Safety Research Group, and the Michigan Health and Hospital Association (2006) Baseline culture assessment taken (April 2006) Developed Science of Safety education (CUSP), and briefing/debriefing tool (May-Sept 2006) Staff education on the Science of Safety (assertion, situational awareness, team communication, and conflict resolution) (September 2006) Roll-out briefings/debriefings (October 2006) Pilot Teams (thoracic and selected orthopedics) A step approach was taken to expand to all operating rooms (Oct 2006-Sept 2007) Over 100,000 briefings/debriefings performed to date Compliance to date average 92% 27
Initial Steps 1. Safety Culture Assessment 2. Educate staff and leadership on Science of Safety - assertion - communication - decision making - embedded into orientation - situational awareness 3. Executive partnership 4. Implement teamwork tools - Surgical briefings/debriefings - Culture debriefing tool 5. Learn from Defects - Tracking/reporting of defects in surgery 28
Initial Steps Keystone Surgery is combination of technical and adaptive methods to implement sustainable change in surgery that ultimately improved patient safety and outcomes Improved teamwork communication (briefings and debriefings) Elimination of mislabeled specimens 29
Initial Steps Reduction in surgical site infections Elimination of retained foreign objects Improved culture of safety 30
Briefing OR teams are comprised of a group of multidisciplinary providers who may or may not know each other Each team member has specific priorities and roles No one is aware of every detail involved in the case Many things happen before the patient arrives in the OR, briefing is the time to share this information 31
Briefing A discussion between the OR team, using succinct information pertinent to the present case. Increases situational awareness through clear and effective communication 32
Briefing Identifies the roles and responsibilities of each team member Key considerations relating to the case Heightens awareness of the situation Allows the team to plan for the unexpected Team members needs and expectations are met 33
Briefing Situational awareness is the ability of the team to have the same understanding of what is occurring during the procedure; the big picture. Focus is on: Preparation and planning Patient care Distraction avoidance 34
Briefing Template 1. ASK ANESTHESIA IF THEY ARE READY TO DO KEYSTONE. 2. ACTIVATE THE AUDITORY SIGNAL (BELL) 3. Ask, CAN EVERYONE PLEAST STOP AND FOCUS ON THE PATIENT? 4. CIRUCLATOR AND ANESTHESIA STAFF, LOOK AT PTs ARM BAND AND CONFIRM NAME AND D.O.B. AGAINST THE CONSENT/CHART. 5. CIRUCULATOR/SURGEON ASKS EVERYONE TO IDENTIFY THEMSELVES. Circulator or Surgeon asks the following questions.. DOCTOR,, can you please state the procedure? Can we confirm sidedness once again? Is the site visible to everyone and is it marked? Does everyone agree that the patient is positioned correctly for the stated procedure? CIRCULATOR, please confirm the following: What images do we have for this patient? 2 staff must confirm correct images. If applicable Is a foley required? If applicable..hcg result? How are we addressing DVT prophylaxis? ANESTHESIA STAFF, can you please tell us the following: What are the patient s allergies? What Antibiotics have been given? Time given? Documentation within SCIP Guidelines? Is a Type and screen required and resulted? Type and Cross? How are we keeping this patient warm? Anything other relevant concerns? (heparin given, glycemic control, etc.) SCRUB TECH, can you please tell us the following: What special instruments do we have on the field for this case? Are there appropriate liquids on the back table in case of a fire? Is there anything else anyone would like to add? In Accordance with Beaumont Policy #463 and Mandatory Keystone Computer Module March 2012 35
Role of the Nurse Initiates briefing process by beginning introductions and verifying information on the white board Are all necessary instruments available? Will any special equipment be considered? Are correct films available Review allergies Plan for breaks Staff that relieve for breaks or at the end of the shift to introduce themselves when switching. 36
Role of Surgeon Discuss risks associated with procedure Provide team with pertinent information, including any anticipated problems Encourages participation from all team members Assures that everyone is familiar with the equipment to be used Any anticipated changes from standard preferences Expected blood loss and length of case At the end of the briefing surgeon states: If anyone has a concern now or during the case, please let me know. 37
Role of Anesthesia Discuss co-morbidities that increase patient s risk Aspects of surgery that increase risk Availability of blood products Abnormal test results impacting the case Discuss position and warming considerations DNR status Interventions to prevent complications 38
Time Out/Final Verification Review Critical Information Is this the correct patient? Is the correct site or side marked? Has the procedure been agreed upon? Have antibiotics been given? 39
Debriefing A process to enhance patient safety that gives the team the opportunity to learn from a shared experience, or significant event that has occurred. A review of pertinent issues at the end of the case. 40
Debriefing An opportunity to discuss what went well and what could be done differently to improve patient care in the future. Identifies barriers to the effective and efficient delivery of care. May define follow up responsibilities of team members 41
Who, when All team members should participate in the debriefing Complete at an appropriate time after first counts have been performed 42
Debriefing Guidelines Remind staff of the purpose and stay focused Reinforce goal: improvement not blame Listen to what others have to say Remember everyone is human! Assign follow up as needed How can information be disseminated to those not present? 43
Review of Critical Information Were counts correct? Are specimens all labeled properly? Post-op diagnosis Verification of procedure completed EBL Any special post-op considerations? (ICU bed, vent etc) 44
Debriefing Questions Did anything occur during the case with the patient or equipment that may have negatively impacted patient care? Were there any breakdowns in team communication that could have been improved? Is there anything that could have been done differently to improve patient care? If so, what follow up is required to correct these situations in the future? Who will be responsible for this follow up? 45
Debriefing Debriefing can lead to: Change in process, more effective future performance Revised or new procedures Improved teamwork Staff satisfaction All of these lead to enhanced patient safety 46
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Briefings/Debriefings Results Findings included: Inappropriate timing of antibiotics Blood not available prior to case starting Equipment not available or unusable Inappropriate timing of DVT prophylaxis Lab results not available Insufficient number of supplies Consent not signed; consent not completed correctly Wrong surgery side marked AICD not being turned off in pre-op 48
What Is In It For the Surgeon? Better patient outcomes! Reduces ill-timed breaks by staff Reduces interruptions and distractions Early resolution of equipment issues Reduced delays in receiving equipment Reduced case delay or cancellations Nundy, S. Arch. Surg. 2008; 143(11): 1068-1072 49
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Beaumont s Findings Effective communication and teamwork are critical in many health care settings, particularly the operating room (OR). Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR. Implementation of a standardized briefing and debriefing tool was a practical and feasible strategy to improve perceptions of interdisciplinary communication and teamwork in the OR. Berneholtz, S.M. et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm Jt Qual Patient Saf. 2009;35(8):391-397. 52
Beaumont s Findings Briefings and debriefings are a practical and effective strategy to surface potential surgical defects in the operating rooms. Further research is needed to evaluate the impact of mitigating defects on clinical and economic outcomes. Bandari J., et al. Surfacing Safety Hazards using Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center. Jt Comm J Qual Patient Saf. 2012;38(4): 154-162 53
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Contact Information William Beaumont Hospital Robert J. Welsh, MD Phone: (248) 898-1049 Email: rwelsh@beaumonthospitals.com 56